Date

Name
Nationality
Date Of Birth
Height (cm)
Weight (Kg)
Sex
Occupation
E-mail address
Telephone #
Fax #
Marital status

Does your complaints aggravate During (please tick)

Exertion Exercise Normal activity Any other Rest
Past Medical History
Family History
Road Traffic Accidents
Surgery
Allergies to any medicine or food

Present complaint with duration (most serious problem first)

Symptoms with duration

1.

2.

3.

4.

 
If already diagnosed - details
Investigated details (if any)

Do you have any of the following

Disease

Select, if you have any

Duration

(in Days/Months/Years)
Current Medication
Diabetes Mellitus
Hypertension
Heart disease
Elevated Cholesterol Level
Bronchial Asthma
Skin infection
Thyroid Problem
Hair falling
Enlarged Prostate
Cancer
Disk problems
Arthritis
Stroke
Sleep disorder
Stress
Mood change
Addiction to tobacco/alcohol
Osteopenia/Osteoporosis
Others
Investigation done – details if available
Diagnosis
Drugs prescribed with dose and how long taking them

Most recent tests done
X-ray Urine Analysis Stool Exam
Colonoscopy Lipid profile PSA
Blood Sugar H.crit Bun
Uric Acid Hb MRI
CT        

Additional Details

 

Details of children

Male Age
Female Age

For Females* (Menstrual Cycle)

Regular
Irregular
Menopause
Pap smear
Mammogram
Hot flush